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Office Use Only ADDITION/ALTERATION PERMIT|Permit: €¢.~ O\\%= 2028 APPLICATION Permit Fee:$_200TownefCoed20=742 Bay Road,Queensbury,NY 12804 Invoice #:_240P:518-761-8256 www.queensbury.net Project Location:15.8 |aKe.Harkylay TaxMapD#:_JAW.I5 -|-Subdivision Name:by 16 CONTACT INFORMATION:X ©Applicant: Name(s):Wrohvard Se)Kaw) Mailing Address,C/S/2:_42 Ne +by,Donvek,AY /o9e4 Cell Phone:G4 36 land Line:_() Email:doth e6sconsulted.Com +Primary Owner(s): Name(s):Ruchar SelKow Mailing Address,C/S/2:4@ Mew\Polt De Aawned WY 109 Cell Phone:_(P/4 )EAL BGA)Land Line:_() Email:_{se|Kow £.au tones cosa |tee»COM O Check if all work will be performed by homeowner only *Contractor(s):Workers’Comp documentation must be submitted with this application Contact Name(s):Poles 8 Ceo Contractor Trade:_Gene(aQ Comtvat for Mailing Address,C/S/Z:Po Way 23/@ Glaus fal)Ax [aso] Cell Phone:(S18 )Q32.}2 5°Land ine:_() Email:iV. **List all additional contractors on the ©Architect(s)/Engineer(s): Business Name:__Ue\|tame J Welltams. Contact Name(s):_Daw, Mailing Address,C/S/Z:_SQ4 Glan s+GJuns Falls,WY Tago Cell Phone:_()landline:(678 )992 484 Email:_vot {|fam<oud Willauss De sieuos a, Contact Person for Building &Code Compliance:_Authony Poo le S Cell Phone:(S79 )X32 1X65 Land Line:_() Email: ‘Additlon/Alteration Application Revised February 2019 PROJECT INFORMATION: Commercial xX ResidentialTYPE: WORK CLASS: X Single-Family __Two-Family __Multi-Family (#of units ) ’ ___Townhouse __Business Office __Retail __Industrial/Warehouse Garage (#of cars )Other (describe.) ADDITION SQUARE FOOTAGE:ALTERATION SQUARE FOOTAGE: Ast floor:Ast floor:_4 8 o.2"floor 3°floor: Basement (habitable space):Basement (habitable space): Total square feet:Total square feet:_SRO ADDITIONAL PROJECT INFORMATION: 1 Estimated Cost of Construction:$___3]JO0 if Commercial project,what is the proposed use: Source of Heat (circle one):Gas Oil CGropane —Solar_—Other Fireplaces need a separate Fuel Burning Appliances &Chimney Application Are there any structures not shown on the plot plan?YES NO Explain: Are there any easements on the property?YES SITE INFORMATION: a.What is the dimensions or acreage of the parcel? b.Isthisacornerlot?YES Wi c.Will the grade be changed as a result of the construction?_YES d.What is the water source?PUBLIC 6 iN wake e Is the parcel on SEWER or a PRIVATE SEPTIC system?Sephiz ‘Additon/Alteration Application Revised February 2019 DECLARATION: 1,|acknowledge that no construction shall be commenced prior to issuance of a valid permit and will be completed within a 12 month period. 2.Ifthework is not completed by the 1 year expiration date the permit may be renewed,subject to fees and department approval. 3.“certify that the application,plans and supporting materials are a true and complete statement and/or description of the work proposed,that all work will be performed in accordance with the NYS Building Codes,local building laws and ordinances,and in conformance with local zoning regulations. 4.|acknowledge that prior to occupying the facilities proposed |,or my agents,will obtain a certificate of occupancy. 5.lalso understand that |Ave are required to provide an as-built survey by a licensed land surveyor of all newly constructed facilities prior to issuance of a certificate of occupancy. |have read and agree to the above: PRINT NAME:AC “Selkow tw doSIGNATURE:A DATE: ‘Addition/Alteration Application Revised February 2018